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血管畸形是怎么回事呢,患者血管畸形的原因(腦血管畸形,會有什么影響呢?)

中醫世(shi)家 2024-05-17 10:55:42

血管(guan)畸形(xing)是怎么回事呢,患者血管(guan)畸形(xing)的原因(yin)

任何一(yi)(yi)個(ge)人都想擁(yong)有健(jian)康(kang)的身體,但是(shi)(shi)這個(ge)是(shi)(shi)不太可(ke)能的事情(qing),因為(wei)生活當(dang)中(zhong)只要(yao)我(wo)們稍微(wei)不注意一(yi)(yi)下,就會出(chu)(chu)現一(yi)(yi)些身體健(jian)康(kang)問題,患上(shang)某一(yi)(yi)種可(ke)怕(pa)的疾病。比如有一(yi)(yi)些人因為(wei)某一(yi)(yi)種原因導致自己(ji)出(chu)(chu)現血管畸形的情(qing)況(kuang),如果生活當(dang)中(zhong)真(zhen)的有人出(chu)(chu)現這種情(qing)況(kuang)的話,他們就要(yao)想辦(ban)法(fa)解決(jue)了。

在了解(jie)血(xue)管(guan)畸形(xing)是(shi)怎么回(hui)事之(zhi)前,我們需要了解(jie)什(shen)么是(shi)血(xue)管(guan)畸形(xing),它是(shi)來源于血(xue)管(guan)或淋巴管(guan)的(de)(de)腫瘤(liu)或畸形(xing)。 患(huan)(huan)(huan)上(shang)這(zhe)種疾病的(de)(de)患(huan)(huan)(huan)者(zhe)大部分(fen)都是(shi)孩子,一般是(shi)剛剛出生沒(mei)有多(duo)久的(de)(de)孩子,所以這(zhe)些孩子一定要多(duo)小心一下才行。孩子之(zhi)所以會患(huan)(huan)(huan)上(shang)這(zhe)種疾病,是(shi)因(yin)為那(nei)些殘余的(de)(de)胚胎成(cheng)血(xue)管(guan)細胞導致的(de)(de)。也(ye)就是(shi)和胎熱(re)、血(xue)熱(re)、心肝兩臟功(gong)能(neng)失調等等原(yuan)因(yin)有關系。患(huan)(huan)(huan)者(zhe)出現(xian)這(zhe)種情(qing)況的(de)(de)時候,往往是(shi)表(biao)現(xian)在患(huan)(huan)(huan)者(zhe)面頸部皮(pi)膚、皮(pi)下組織、口腔黏(nian)膜等等地(di)方的(de)(de),所以患(huan)(huan)(huan)者(zhe)要多(duo)注意(yi)一下。

如果(guo)(guo)患者真的(de)不幸出現(xian)血管(guan)畸形這(zhe)種(zhong)(zhong)情況的(de)話(hua),患者一定要想辦(ban)法治療(liao)(liao)(liao)(liao)才行。目前(qian)治療(liao)(liao)(liao)(liao)這(zhe)種(zhong)(zhong)疾病的(de)方法是很多(duo)的(de),比如外科切除、放射治療(liao)(liao)(liao)(liao)、激素(su)治療(liao)(liao)(liao)(liao)、低溫治療(liao)(liao)(liao)(liao)、激光治療(liao)(liao)(liao)(liao)、硬化劑注射等(deng)等(deng)都是不錯的(de)治療(liao)(liao)(liao)(liao)方法,一般情況下,醫生是選擇幫患者進(jin)行綜合療(liao)(liao)(liao)(liao)法的(de),因為這(zhe)樣(yang)治療(liao)(liao)(liao)(liao)效果(guo)(guo)會(hui)更加(jia)的(de)好。如果(guo)(guo)患者病情嚴重(zhong)的(de)話(hua),患者可以采取一定的(de)手術治療(liao)(liao)(liao)(liao)方法來解(jie)決。

血管畸形對患(huan)(huan)者(zhe)(zhe)的(de)影響(xiang)是(shi)很大的(de),所以患(huan)(huan)者(zhe)(zhe)一(yi)(yi)定(ding)要(yao)想方設(she)法解決(jue)掉(diao)這個問題(ti)才(cai)行,也就(jiu)是(shi)通過上面(mian)的(de)治(zhi)療(liao)方法來解決(jue)。如(ru)果患(huan)(huan)者(zhe)(zhe)病情還是(shi)很嚴重的(de)話,患(huan)(huan)者(zhe)(zhe)一(yi)(yi)定(ding)要(yao)在第(di)一(yi)(yi)時間去醫院(yuan)檢查看一(yi)(yi)看,到底是(shi)怎么回事,千萬不(bu)要(yao)自己盲目治(zhi)療(liao)。

腦(nao)血(xue)管(guan)畸形(xing),會有什么影響呢?

引言:腦(nao)(nao)血管畸(ji)(ji)形(xing)屬于先(xian)天性的(de)血管發育(yu)異(yi)常疾病(bing)(bing),大(da)部分人(ren)會在40歲以前患(huan)病(bing)(bing)。并且腦(nao)(nao)血管畸(ji)(ji)形(xing)能發生(sheng)在動(dong)脈靜(jing)(jing)脈毛細血管。其(qi)中動(dong)脈靜(jing)(jing)脈型血管畸(ji)(ji)形(xing)最(zui)為常見(jian),占(zhan)患(huan)病(bing)(bing)人(ren)數(shu)的(de)78%。病(bing)(bing)情嚴重的(de)情況(kuang)下,會造成畸(ji)(ji)形(xing)血管的(de)破裂,會造成蛛網膜下腔出血或(huo)者是腦(nao)(nao)出血。所以今(jin)天小(xiao)編想(xiang)分享的(de)話題就是,腦(nao)(nao)血管畸(ji)(ji)形(xing)會有哪(na)些影響(xiang)?

一、什么是腦血管畸形?

腦(nao)血(xue)(xue)管畸(ji)形又叫腦(nao)血(xue)(xue)管瘤,腦(nao)動靜脈(mo)性(xing)血(xue)(xue)管畸(ji)形。是(shi)腦(nao)血(xue)(xue)管先天性(xing)無腫瘤性(xing)的(de)(de)發(fa)育(yu)(yu)異常(chang)現象,而且是(shi)腦(nao)血(xue)(xue)管發(fa)育(yu)(yu)障礙而導致的(de)(de)局部(bu)血(xue)(xue)管數量結構發(fa)生異常(chang),并且對正常(chang)的(de)(de)腦(nao)血(xue)(xue)流產生一(yi)(yi)定的(de)(de)影響。造(zao)成(cheng)腦(nao)血(xue)(xue)管畸(ji)形的(de)(de)病因有動靜脈(mo)畸(ji)形,先天性(xing)顱內囊性(xing)動脈(mo)瘤,靜脈(mo)血(xue)(xue)管瘤,海綿(mian)狀血(xue)(xue)管瘤。常(chang)見的(de)(de)臨(lin)床表(biao)現就是(shi)搏(bo)動性(xing)的(de)(de)頭(tou)痛,出血(xue)(xue),癲癇(xian),會出現一(yi)(yi)些偏(pian)癱,失語,失算,眩暈,眼顫等癥狀。

二、腦血管畸形會有哪些(xie)影響?

會(hui)造成意識障(zhang)(zhang)礙,會(hui)讓患者表現出(chu)精神狀態不(bu)佳,精神萎靡不(bu)振,總有昏(hun)昏(hun)欲(yu)睡(shui)的(de)(de)(de)感覺,并(bing)且性格也(ye)會(hui)改變(bian),會(hui)從喋喋不(bu)休(xiu)變(bian)成沉默寡言(yan)。會(hui)出(chu)現短暫(zan)性的(de)(de)(de)意識喪失,神經功(gong)能(neng)(neng)(neng)也(ye)會(hui)出(chu)現障(zhang)(zhang)礙。最常(chang)見的(de)(de)(de)就是(shi)運動障(zhang)(zhang)礙,感覺障(zhang)(zhang)礙,視力(li)(li)障(zhang)(zhang)礙,不(bu)能(neng)(neng)(neng)說話(hua)。而且會(hui)造成頭痛現象,頭痛也(ye)是(shi)腦血管(guan)畸形(xing)最常(chang)見的(de)(de)(de)癥狀之一。頭痛的(de)(de)(de)原因,主(zhu)要就是(shi)腦血管(guan)擴張,出(chu)現顱內(nei)壓力(li)(li)增高(gao)或者是(shi)顱內(nei)出(chu)血,并(bing)且會(hui)伴隨(sui)一定的(de)(de)(de)惡心(xin),嘔吐現象。會(hui)誘發(fa)癲(dian)癇(xian),在(zai)發(fa)作時會(hui)導(dao)致患者智力(li)(li)降(jiang)低(di),出(chu)現神經功(gong)能(neng)(neng)(neng)障(zhang)(zhang)礙,還會(hui)伴隨(sui)一些其(qi)他的(de)(de)(de)癥狀,例如周圍腦組織缺血,腦細胞變(bian)性,發(fa)育障(zhang)(zhang)礙,智力(li)(li)下(xia)降(jiang),生活不(bu)能(neng)(neng)(neng)自理,呼吸(xi)驟停(ting),會(hui)危害到人體的(de)(de)(de)健康。

脊髓血管畸形是(shi)怎么引起的?

(一)發病原因
脊髓血管畸形系先天性病變,對其認識以病理解剖為基礎,以動脈或靜脈畸形為主要病變,過去著重在靜脈的病理生理影響。在磁共振及選擇性脊髓血管造影的基礎上,結合大體病理所見。現將脊髓血管畸形分為四種主要類型(表1):
(二)發病機制
1.Ⅰ型Ⅰ型為硬膜動靜脈畸形,動靜脈畸形形成交通位于硬膜,通常累及神經根袖或胸腰段椎管后外側硬膜,位于神經孔內。硬膜動靜脈畸形的動脈供應來源于脊柱的節段動脈的硬膜分支,供應神經根和硬膜。在硬膜內較低的血流量經病變處,其靜脈回流至硬膜內,再回流到脊髓的冠狀靜脈。此組靜脈位于脊髓背外側,無靜脈瓣。因而脊柱的節段動脈與脊髓回流靜脈之間形成動靜脈瘺交通。此瘺亦與脊髓后側和后外側的冠狀靜脈瘺交通。此瘺亦與脊髓后側和后外側的冠狀靜脈叢之間也形成交通。冠狀靜脈叢的血流向上流向枕骨大孔。15%動脈靜脈瘺平面的節段動脈供應脊髓前動脈或脊髓后動脈。病變處通常只有1根滋養動脈,但亦有2根以上多根的滋養動脈。Anson和Spetzler根據滋養動脈的數量,將Ⅰ型進一步分為亞型Ⅰa為單一滋養動脈,Ⅰb為多根滋養動脈,此通常在1個或相互毗鄰的兩個節段處。硬膜動靜脈瘺平均靜壓約為全身動脈壓的74%。血流動力學證據顯示:Ⅰ型硬膜動靜脈畸形神經功能障礙的病理生理主要是由于靜脈壓的升高所致,表現為冠狀靜脈充血、擴張,繼之壓迫脊髓,但此種脊髓神經功能障礙為可逆性損害。
2.Ⅱ型Ⅱ型為血管球狀畸形,在髓內有一動靜脈血管團,這些病變常常見于頸脊髓內,但也可發生于胸腰段的任何部位。其特點在血管造影中顯示為高血流量和稀疏的靜脈回流血管。常有靜脈瘤和靜脈曲張。
3.Ⅲ型脊髓血管畸形最初稱之為“未成熟畸形”,以高血流量和廣泛而復雜的動、靜脈解剖為特點。病變可占據整個脊髓,侵及硬膜,甚至延及椎體和椎旁組織。
4.Ⅳ型脊髓血管畸形位于硬膜內-脊髓外區,脊髓前動脈的一根分支為動靜脈畸形的滋養動脈,然后經瘺回流到大小不等的髓外靜脈。動靜脈瘺及其回流靜脈位于脊髓外,病變不在脊髓內。此類病變通常位于胸腰連接處。Anson和Spetzler將Ⅳ型進一步分為亞型:Ⅳa型相對較小,髓外動靜脈瘺由單一滋養動脈供應,通常位于腹側一直延及圓錐。Ⅳb型一條以上滋養動脈,通常來自脊髓前動脈和多根滋養動脈來源于脊髓后動脈。通過這些病變的血流較通過Ⅳa型瘺的血流量大。Ⅳc型的特點是由多條供應動脈與瘺相連。病變的靜脈血回流量常常很大,胸腰椎管的腹側和腹外側常有擴張的靜脈曲張。
Ⅱ、Ⅲ、Ⅳ型脊髓血管畸形,原屬于硬膜內血管畸形。除上述4型以外,尚有海綿狀血管畸形。
5.海綿狀血(xue)(xue)管(guan)畸形(xing)海綿狀血(xue)(xue)管(guan)畸形(xing)可(ke)以(yi)單一病變(bian)存在或(huo)為顱脊髓(sui)海綿狀血(xue)(xue)管(guan)瘤的(de)(de)一部分(fen)的(de)(de)形(xing)式發(fa)生在脊髓(sui)內(nei)(nei)。這(zhe)(zhe)些低血(xue)(xue)流量的(de)(de)病變(bian)由脊髓(sui)實(shi)質(zhi)內(nei)(nei)分(fen)層狀的(de)(de)血(xue)(xue)管(guan)或(huo)多節段的(de)(de)血(xue)(xue)管(guan)通道組成,可(ke)以(yi)發(fa)生根管(guan)內(nei)(nei)出血(xue)(xue)或(huo)者壓迫癥狀。海綿狀血(xue)(xue)管(guan)瘤可(ke)發(fa)生于整個中樞神經系統。這(zhe)(zhe)些病變(bian)由一些菲薄(bo)的(de)(de)沒有明顯彈(dan)性(xing)蛋(dan)白(bai)或(huo)平滑(hua)肌的(de)(de)血(xue)(xue)管(guan)壁(bi)(bi)層的(de)(de)血(xue)(xue)管(guan)組成。這(zhe)(zhe)些薄(bo)壁(bi)(bi)管(guan)道襯以(yi)內(nei)(nei)皮(pi)細胞,常(chang)常(chang)有陳舊(jiu)出血(xue)(xue)的(de)(de)表現。在血(xue)(xue)管(guan)壁(bi)(bi)之間看不到(dao)散(san)在分(fen)布(bu)的(de)(de)正常(chang)脊髓(sui)或(huo)腦實(shi)質(zhi)。

動靜脈型(xing)血管畸形簡介(jie)

目錄 1 概(gai)述 2 疾病(bing)(bing)名(ming)稱 3 英(ying)文名(ming)稱 4 動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)脈(mo)(mo)(mo)(mo)型(xing)血(xue)(xue)(xue)(xue)管(guan)(guan)畸(ji)(ji)形的(de)(de)(de)別名(ming) 5 分類 6 ICD號 7 流行病(bing)(bing)學(xue) 8 病(bing)(bing)因(yin) 9 發(fa)病(bing)(bing)機制(zhi) 10 迪(di)厄(e)拉(la)富(fu)(fu)瓦病(bing)(bing)的(de)(de)(de)臨(lin)(lin)床表(biao)現(xian) 11 迪(di)厄(e)拉(la)富(fu)(fu)瓦病(bing)(bing)的(de)(de)(de)并發(fa)癥 12 實驗室檢(jian)(jian)查(cha) 13 輔(fu)助檢(jian)(jian)查(cha) 13.1 內鏡(jing) 13.2 選擇性(xing)血(xue)(xue)(xue)(xue)管(guan)(guan)造影 13.3 核(he)素檢(jian)(jian)查(cha) 14 診(zhen)斷(duan) 15 鑒別診(zhen)斷(duan) 16 迪(di)厄(e)拉(la)富(fu)(fu)瓦病(bing)(bing)的(de)(de)(de)治(zhi)(zhi)療(liao)(liao)(liao) 16.1 內鏡(jing)治(zhi)(zhi)療(liao)(liao)(liao) 16.1.1 注射治(zhi)(zhi)療(liao)(liao)(liao) 16.1.2 熱探頭凝(ning)固治(zhi)(zhi)療(liao)(liao)(liao) 16.1.3 微波凝(ning)固治(zhi)(zhi)療(liao)(liao)(liao) 16.1.4 高頻電(dian)凝(ning)治(zhi)(zhi)療(liao)(liao)(liao) 16.1.5 激光治(zhi)(zhi)療(liao)(liao)(liao) 16.1.6 注射聯合熱治(zhi)(zhi)療(liao)(liao)(liao) 16.1.7 止血(xue)(xue)(xue)(xue)夾治(zhi)(zhi)療(liao)(liao)(liao) 16.1.8 套扎(zha)治(zhi)(zhi)療(liao)(liao)(liao) 16.2 栓塞(sai)治(zhi)(zhi)療(liao)(liao)(liao) 16.3 手術治(zhi)(zhi)療(liao)(liao)(liao) 17 相關藥品 18 相關檢(jian)(jian)查(cha) 附: 1 治(zhi)(zhi)療(liao)(liao)(liao)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)脈(mo)(mo)(mo)(mo)型(xing)血(xue)(xue)(xue)(xue)管(guan)(guan)畸(ji)(ji)形的(de)(de)(de)穴位(wei)(wei) 這(zhe)是一(yi)個重定向條目,共享了迪(di)厄(e)拉(la)富(fu)(fu)瓦病(bing)(bing)的(de)(de)(de)內容。為(wei)方(fang)便(bian)閱讀,下(xia)文中(zhong)的(de)(de)(de) 迪(di)厄(e)拉(la)富(fu)(fu)瓦病(bing)(bing) 已經自動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)替換為(wei) 動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)脈(mo)(mo)(mo)(mo)型(xing)血(xue)(xue)(xue)(xue)管(guan)(guan)畸(ji)(ji)形 ,可 點此恢復原(yuan)貌 ,或 使用(yong)(yong)備注方(fang)式展(zhan)現(xian) 1 概(gai)述 動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)脈(mo)(mo)(mo)(mo)型(xing)血(xue)(xue)(xue)(xue)管(guan)(guan)畸(ji)(ji)形(Dieulafoy’s disease)又稱Dieulafoy病(bing)(bing)變(bian)(Dieulafoy’s lesion),是引起消化(hua)道(dao)(dao)(dao)尤其是上消化(hua)道(dao)(dao)(dao)大出(chu)(chu)血(xue)(xue)(xue)(xue)的(de)(de)(de)原(yuan)因(yin)之一(yi)。至今(jin)尚無(wu)(wu)一(yi)個確切的(de)(de)(de)定義,病(bing)(bing)變(bian)是突(tu)露于(yu)胃(wei)(wei)(wei)腸道(dao)(dao)(dao)腔內活動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)出(chu)(chu)血(xue)(xue)(xue)(xue)的(de)(de)(de)或黏(nian)附血(xue)(xue)(xue)(xue)塊的(de)(de)(de)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo),動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)周圍無(wu)(wu)潰瘍形成(cheng)這(zhe)一(yi)特(te)(te)征已成(cheng)為(wei)多數學(xue)者共識。動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)脈(mo)(mo)(mo)(mo)型(xing)血(xue)(xue)(xue)(xue)管(guan)(guan)畸(ji)(ji)形可以(yi)發(fa)生(sheng)在胃(wei)(wei)(wei)腸道(dao)(dao)(dao)的(de)(de)(de)任何(he)部(bu)位(wei)(wei),以(yi)近(jin)端胃(wei)(wei)(wei)最多見。1898年,Dieulafoy最早報道(dao)(dao)(dao)了3例因(yin)胃(wei)(wei)(wei)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)破裂(lie)(lie)(lie)致上消化(hua)道(dao)(dao)(dao)大出(chu)(chu)血(xue)(xue)(xue)(xue)而死亡的(de)(de)(de)患者,并認為(wei)病(bing)(bing)灶是胃(wei)(wei)(wei)黏(nian)膜(mo)淺(qian)(qian)表(biao)性(xing)潰瘍引起胃(wei)(wei)(wei)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)破裂(lie)(lie)(lie),出(chu)(chu)血(xue)(xue)(xue)(xue)中(zhong)斷(duan)了病(bing)(bing)變(bian)的(de)(de)(de)進一(yi)步發(fa)展(zhan)。此后,Dieulafoy的(de)(de)(de)名(ming)字與胃(wei)(wei)(wei)黏(nian)膜(mo)下(xia)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)破裂(lie)(lie)(lie)出(chu)(chu)血(xue)(xue)(xue)(xue)聯系在一(yi)起。早期由(you)于(yu)對(dui)該病(bing)(bing)的(de)(de)(de)病(bing)(bing)理性(xing)質缺(que)乏深入的(de)(de)(de)研(yan)究,文獻報道(dao)(dao)(dao)中(zhong)所用(yong)(yong)名(ming)稱不一(yi),如(ru)Dieulafoy血(xue)(xue)(xue)(xue)管(guan)(guan)畸(ji)(ji)形、Dieulafoy胃(wei)(wei)(wei)黏(nian)膜(mo)糜爛、淺(qian)(qian)表(biao)性(xing)潰瘍、胃(wei)(wei)(wei)黏(nian)膜(mo)下(xia)恒(heng)徑動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)破裂(lie)(lie)(lie)出(chu)(chu)血(xue)(xue)(xue)(xue)、胃(wei)(wei)(wei)黏(nian)膜(mo)下(xia)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)硬化(hua)、黏(nian)膜(mo)下(xia)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)畸(ji)(ji)形、曲張性(xing)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)瘤(liu)、胃(wei)(wei)(wei)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)瘤(liu)、動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)脈(mo)(mo)(mo)(mo)畸(ji)(ji)形、特(te)(te)殊位(wei)(wei)置的(de)(de)(de)消化(hua)性(xing)潰瘍等。1988年,Saueraber報道(dao)(dao)(dao)了7例患者,并通(tong)過文獻復習,詳(xiang)細(xi)闡明了該病(bing)(bing)的(de)(de)(de)發(fa)病(bing)(bing)機制(zhi)、病(bing)(bing)理、臨(lin)(lin)床特(te)(te)征、診(zhen)斷(duan)及治(zhi)(zhi)療(liao)(liao)(liao)方(fang)法(fa)。近(jin)年由(you)于(yu)內鏡(jing)的(de)(de)(de)廣泛應用(yong)(yong),該病(bing)(bing)的(de)(de)(de)報道(dao)(dao)(dao)日益(yi)增多并統(tong)一(yi)稱為(wei)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)脈(mo)(mo)(mo)(mo)型(xing)血(xue)(xue)(xue)(xue)管(guan)(guan)畸(ji)(ji)形。

2 疾病名稱(cheng) 動靜脈型血(xue)管畸形(xing)

3 英文名(ming)稱(cheng) Dieulafoy disease

4 動靜脈(mo)(mo)型血管畸(ji)形的別名 Dieulafoy病(bing);Dieulafoy病(bing)變(bian);Dieulafoy胃黏(nian)(nian)(nian)膜(mo)糜爛;Dieulafoy血管畸(ji)形;動靜脈(mo)(mo)畸(ji)形;迪厄拉(la)富瓦病(bing);黏(nian)(nian)(nian)膜(mo)下(xia)動脈(mo)(mo)畸(ji)形;淺表(biao)性(xing)潰瘍;曲張性(xing)動脈(mo)(mo)瘤;特殊(shu)位置的消化性(xing)潰瘍;胃動脈(mo)(mo)瘤;胃黏(nian)(nian)(nian)膜(mo)下(xia)動脈(mo)(mo)硬(ying)化;胃黏(nian)(nian)(nian)膜(mo)下(xia)恒徑動脈(mo)(mo)破裂(lie)出血

5 分類 消化科 > 胃十二指腸(chang)疾病 > 胃其他疾病

6 ICD號(hao) K31.8

7 流行(xing)病(bing)學 動靜(jing)脈型血管(guan)畸形(xing)相(xiang)對少見(jian)(jian),西(xi)方發達國(guo)家占(zhan)上消化道大出血病(bing)例(li)(li)(li)(li)(li)(li)的(de)(de)0.3%~6.8%,日(ri)(ri)本為1.1%~9.4%,Dieulafoy報(bao)道的(de)(de)7個病(bing)例(li)(li)(li)(li)(li)(li)平均年(nian)(nian)齡(ling)33.7歲,男(nan)(nan)女比(bi)1.3∶1,大致相(xiang)等。近(jin)年(nian)(nian)田中收集日(ri)(ri)本93例(li)(li)(li)(li)(li)(li),平均年(nian)(nian)齡(ling)53.9歲,男(nan)(nan)女比(bi)3.2∶1,男(nan)(nan)性多(duo)。美國(guo)Norton等報(bao)道1組89例(li)(li)(li)(li)(li)(li),平均年(nian)(nian)齡(ling)72歲,提示高齡(ling)者(zhe)多(duo)見(jian)(jian)。病(bing)死(si)(si)率(lv)1898年(nian)(nian)Dieulafoy報(bao)道的(de)(de)7例(li)(li)(li)(li)(li)(li)6例(li)(li)(li)(li)(li)(li)死(si)(si)亡(wang),1964年(nian)(nian)Glodmen報(bao)道24例(li)(li)(li)(li)(li)(li)19例(li)(li)(li)(li)(li)(li)(79%)死(si)(si)亡(wang)。Zanten等報(bao)道1970~1984年(nian)(nian)35例(li)(li)(li)(li)(li)(li)8例(li)(li)(li)(li)(li)(li)(23%)死(si)(si)亡(wang),1999年(nian)(nian)Norton等報(bao)道89例(li)(li)(li)(li)(li)(li)中12例(li)(li)(li)(li)(li)(li)(13%)死(si)(si)亡(wang)。病(bing)死(si)(si)率(lv)在(zai)逐年(nian)(nian)下降,原因與內鏡的(de)(de)普及和(he)治療的(de)(de)進步有關。

8 病因(yin) 動(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)(jing)(jing)(jing)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)型(xing)血管(guan)(guan)(guan)畸(ji)形(xing)(xing)(xing)(xing)(xing)的發(fa)(fa)(fa)病機制(zhi)尚不完全(quan)清楚,過(guo)去曾(ceng)將動(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)(jing)(jing)(jing)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)型(xing)血管(guan)(guan)(guan)畸(ji)形(xing)(xing)(xing)(xing)(xing)歸為(wei)(wei)(wei)(wei)胃(wei)動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)瘤(liu)(liu),認(ren)為(wei)(wei)(wei)(wei)出血是由(you)于(yu)動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)瘤(liu)(liu)的擴張、破(po)(po)裂(lie)(lie)(lie)所致(zhi),但近來病理檢查發(fa)(fa)(fa)現動(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)(jing)(jing)(jing)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)型(xing)血管(guan)(guan)(guan)畸(ji)形(xing)(xing)(xing)(xing)(xing)的血管(guan)(guan)(guan)有(you)內膜(mo)(mo)(mo)(mo)、中層和(he)外膜(mo)(mo)(mo)(mo),排除了動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)瘤(liu)(liu)的可(ke)(ke)能(neng),也曾(ceng)認(ren)為(wei)(wei)(wei)(wei)動(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)(jing)(jing)(jing)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)型(xing)血管(guan)(guan)(guan)畸(ji)形(xing)(xing)(xing)(xing)(xing)是先(xian)天(tian)(tian)性動(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)(jing)(jing)(jing)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)畸(ji)形(xing)(xing)(xing)(xing)(xing),但研(yan)究(jiu)中未發(fa)(fa)(fa)現動(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)(jing)(jing)(jing)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)畸(ji)形(xing)(xing)(xing)(xing)(xing)的存(cun)在。正常(chang)(chang)(chang)情況下(xia)胃(wei)壁血供主要來自于(yu)胃(wei)短動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo),進入(ru)胃(wei)壁后(hou)分支逐漸(jian)變細(xi),最(zui)終在胃(wei)黏(nian)(nian)(nian)膜(mo)(mo)(mo)(mo)形(xing)(xing)(xing)(xing)(xing)成毛細(xi)血管(guan)(guan)(guan)系(xi)統,但動(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)(jing)(jing)(jing)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)型(xing)血管(guan)(guan)(guan)畸(ji)形(xing)(xing)(xing)(xing)(xing)患者胃(wei)短動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)分支進入(ru)胃(wei)黏(nian)(nian)(nian)膜(mo)(mo)(mo)(mo)肌(ji)層后(hou)保持恒(heng)(heng)(heng)定的直徑(jing)(jing)(jing)(jing)(jing),因(yin)而稱為(wei)(wei)(wei)(wei)恒(heng)(heng)(heng)徑(jing)(jing)(jing)(jing)(jing)動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)。一(yi)般認(ren)為(wei)(wei)(wei)(wei)恒(heng)(heng)(heng)徑(jing)(jing)(jing)(jing)(jing)動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)是先(xian)天(tian)(tian)性發(fa)(fa)(fa)育(yu)異常(chang)(chang)(chang),恒(heng)(heng)(heng)徑(jing)(jing)(jing)(jing)(jing)動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)與黏(nian)(nian)(nian)膜(mo)(mo)(mo)(mo)之(zhi)間有(you)著特(te)殊(shu)的關(guan)(guan)系(xi),正常(chang)(chang)(chang)情況下(xia)黏(nian)(nian)(nian)膜(mo)(mo)(mo)(mo)下(xia)疏(shu)松組織使得(de)動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)表面的黏(nian)(nian)(nian)膜(mo)(mo)(mo)(mo)自由(you)移動(dong)(dong)(dong)(dong)(dong)(dong),而動(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)(jing)(jing)(jing)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)型(xing)血管(guan)(guan)(guan)畸(ji)形(xing)(xing)(xing)(xing)(xing)患者由(you)于(yu)Wanken纖維束將動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)和(he)黏(nian)(nian)(nian)膜(mo)(mo)(mo)(mo)固(gu)定,形(xing)(xing)(xing)(xing)(xing)成特(te)定的黏(nian)(nian)(nian)膜(mo)(mo)(mo)(mo)易(yi)損(sun)區,Wanken纖維束與動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)和(he)黏(nian)(nian)(nian)膜(mo)(mo)(mo)(mo)的關(guan)(guan)系(xi)可(ke)(ke)能(neng)為(wei)(wei)(wei)(wei)先(xian)天(tian)(tian)性所致(zhi)。黏(nian)(nian)(nian)膜(mo)(mo)(mo)(mo)易(yi)損(sun)區在外界因(yin)素(su) 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下(xia),發(fa)(fa)(fa)生黏(nian)(nian)(nian)膜(mo)(mo)(mo)(mo)損(sun)傷并引起黏(nian)(nian)(nian)膜(mo)(mo)(mo)(mo)下(xia)恒(heng)(heng)(heng)徑(jing)(jing)(jing)(jing)(jing)動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)破(po)(po)裂(lie)(lie)(lie);隨(sui)著年(nian)齡增大,動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)管(guan)(guan)(guan)徑(jing)(jing)(jing)(jing)(jing)擴張,黏(nian)(nian)(nian)膜(mo)(mo)(mo)(mo)萎縮(suo),這種(zhong)薄弱的環境(jing)更(geng)易(yi)受到損(sun)害。因(yin)此,動(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)(jing)(jing)(jing)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)型(xing)血管(guan)(guan)(guan)畸(ji)形(xing)(xing)(xing)(xing)(xing)灶是由(you)黏(nian)(nian)(nian)膜(mo)(mo)(mo)(mo)下(xia)恒(heng)(heng)(heng)徑(jing)(jing)(jing)(jing)(jing)動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)和(he)淺(qian)表性黏(nian)(nian)(nian)膜(mo)(mo)(mo)(mo)糜爛構成。多(duo)種(zhong)因(yin)素(su)可(ke)(ke)促使胃(wei)黏(nian)(nian)(nian)膜(mo)(mo)(mo)(mo)糜爛和(he)恒(heng)(heng)(heng)徑(jing)(jing)(jing)(jing)(jing)動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)破(po)(po)裂(lie)(lie)(lie),如大量飲酒(jiu)、吸煙、膽汁(zhi)反流均可(ke)(ke)引起胃(wei)黏(nian)(nian)(nian)膜(mo)(mo)(mo)(mo)糜爛;胃(wei)蠕(ru)動(dong)(dong)(dong)(dong)(dong)(dong)時(shi)恒(heng)(heng)(heng)徑(jing)(jing)(jing)(jing)(jing)動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)受壓、拉長,蠕(ru)動(dong)(dong)(dong)(dong)(dong)(dong)時(shi)產生的切(qie)割(ge)力(li)或機械性損(sun)傷亦可(ke)(ke)引起血管(guan)(guan)(guan)破(po)(po)裂(lie)(lie)(lie)。恒(heng)(heng)(heng)徑(jing)(jing)(jing)(jing)(jing)動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)并不是突然(ran)腐蝕破(po)(po)裂(lie)(lie)(lie),而是由(you)于(yu)管(guan)(guan)(guan)壁逐漸(jian)變薄、擴張而致(zhi)破(po)(po)裂(lie)(lie)(lie),破(po)(po)裂(lie)(lie)(lie)前常(chang)(chang)(chang)有(you)血栓(shuan)形(xing)(xing)(xing)(xing)(xing)成。有(you)些研(yan)究(jiu)發(fa)(fa)(fa)現,動(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)(jing)(jing)(jing)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)型(xing)血管(guan)(guan)(guan)畸(ji)形(xing)(xing)(xing)(xing)(xing)灶血管(guan)(guan)(guan)存(cun)在不同(tong)程度的動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)硬(ying)化,血管(guan)(guan)(guan)的硬(ying)化更(geng)易(yi)發(fa)(fa)(fa)生破(po)(po)裂(lie)(lie)(lie),這種(zhong)現象(xiang)可(ke)(ke)以解釋(shi)動(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)(jing)(jing)(jing)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)型(xing)血管(guan)(guan)(guan)畸(ji)形(xing)(xing)(xing)(xing)(xing)的發(fa)(fa)(fa)病年(nian)齡偏(pian)大。

9 發病機(ji)制 動靜脈(mo)型血(xue)管(guan)畸形(xing)的(de)組織病理具有(you)兩個典(dian)型特(te)征:病灶(zao)小(xiao),多呈2~5mm卵圓形(xing)淺表性糜爛,可深達(da)黏(nian)膜(mo)肌層,在黏(nian)膜(mo)灶(zao)的(de)中央可見直(zhi)徑1~3mm動脈(mo)突(tu)出于黏(nian)膜(mo)缺損的(de)部(bu)位(wei)(wei),表面可有(you)血(xue)栓附著,病灶(zao)周圍(wei)黏(nian)膜(mo)無炎癥(zheng)改變,由于病灶(zao)小(xiao),內鏡(jing)檢查(cha)時易于忽視(shi);位(wei)(wei)置特(te)殊,動靜脈(mo)型血(xue)管(guan)畸形(xing)灶(zao)常位(wei)(wei)于胃賁(bi)門部(bu)小(xiao)彎側(ce),Zanten報(bao)道82%的(de)病灶(zao)位(wei)(wei)于食管(guan)與(yu)胃連(lian)接的(de)6cm內,81%的(de)病灶(zao)位(wei)(wei)于胃小(xiao)彎側(ce),亦有(you)極少數病灶(zao)位(wei)(wei)于十二指腸(chang)、空腸(chang)和結(jie)、直(zhi)腸(chang)。

動靜(jing)脈型血管畸形的病灶(zao)在顯微鏡(jing)下的病理(li)特征是:

1.胃黏膜淺表性(xing)局灶性(xing)缺損(sun)伴有基底部(bu)纖(xian)維樣壞(huai)死(si)。

2.在(zai)缺損(sun)的基底部(bu)有較(jiao)大(da)的動(dong)(dong)脈(mo),動(dong)(dong)脈(mo)壁增厚;黏(nian)膜肌層有扭曲、增生(sheng)的動(dong)(dong)脈(mo)。

3.與黏膜肌層動脈(mo)伴隨的靜脈(mo)管徑增粗。

高倍鏡下(xia)(xia)可見破(po)裂的動(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)壁(bi)有(you)輕度炎癥反(fan)應,管(guan)(guan)腔內纖(xian)(xian)維(wei)(wei)血(xue)栓(shuan)形(xing)成,動(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)管(guan)(guan)壁(bi)黏(nian)(nian)膜(mo)下(xia)(xia)纖(xian)(xian)維(wei)(wei)沉著,胃黏(nian)(nian)膜(mo)肌層增(zeng)厚,病(bing)灶周(zhou)圍(wei)黏(nian)(nian)膜(mo)無(wu)炎癥反(fan)應。采用彈(dan)力纖(xian)(xian)維(wei)(wei)染色發(fa)現破(po)裂動(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)壁(bi)周(zhou)圍(wei)彈(dan)力纖(xian)(xian)維(wei)(wei)組織松(song)解,動(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)壁(bi)無(wu)瘤樣(yang)擴張,亦(yi)無(wu)動(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)炎的存在(圖(tu)1)。Miko分(fen)析(xi)了24例動(dong)(dong)(dong)(dong)(dong)靜脈(mo)(mo)(mo)(mo)型(xing)血(xue)管(guan)(guan)畸形(xing)出(chu)血(xue)動(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)與(yu)正(zheng)常動(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)的組織病(bing)理(li)區別,發(fa)現動(dong)(dong)(dong)(dong)(dong)靜脈(mo)(mo)(mo)(mo)型(xing)血(xue)管(guan)(guan)畸形(xing)出(chu)血(xue)動(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)有(you)正(zheng)常的組織結(jie)構,即由(you)黏(nian)(nian)膜(mo)、肌層和外膜(mo)構成。黏(nian)(nian)膜(mo)下(xia)(xia)動(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)管(guan)(guan)徑(jing)正(zheng)常,血(xue)管(guan)(guan)的增(zeng)粗主(zhu)要表現在黏(nian)(nian)膜(mo)肌層,動(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)通過Wanken彈(dan)力纖(xian)(xian)維(wei)(wei)固定(ding)于黏(nian)(nian)膜(mo),動(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)(mo)(mo)裂口處有(you)黏(nian)(nian)膜(mo)缺損,伴(ban)隨(sui)的靜脈(mo)(mo)(mo)(mo)亦(yi)有(you)破(po)裂。

10 動(dong)靜脈(mo)型(xing)血(xue)(xue)管畸形的臨床表(biao)現 動(dong)靜脈(mo)型(xing)血(xue)(xue)管畸形的主要臨床表(biao)現是反(fan)復發作性(xing)嘔血(xue)(xue)和柏油樣大便,嚴重者可出現失血(xue)(xue)性(xing)休克;出血(xue)(xue)前(qian)無明(ming)顯上腹部不適和疼痛,亦(yi)無消化道(dao)潰瘍病史(shi)和家族遺傳史(shi)。

11 動靜脈(mo)型(xing)血管畸形的并發癥 動靜脈(mo)型(xing)血管畸形的主要臨床表(biao)現是反復(fu)發作性嘔血和柏油樣(yang)大便,嚴重者可出現失血性休克。

12 實驗室(shi)檢(jian)查(cha) 1.大便潛血實驗可為(wei)陽性。

2.血常規檢(jian)查血紅蛋(dan)白(bai)總量下(xia)降。

13 輔助檢查

13.1 內鏡

內(nei)(nei)(nei)鏡(jing)的(de)診斷(duan)取決于檢查者對動(dong)靜脈型血(xue)(xue)(xue)(xue)(xue)管畸形的(de)認識和經驗。動(dong)靜脈型血(xue)(xue)(xue)(xue)(xue)管畸形在內(nei)(nei)(nei)鏡(jing)下的(de)表(biao)現不一(圖2),主要特征是:賁門區胃黏膜局灶(zao)性(xing)缺損伴有(you)噴(pen)射樣(yang)出(chu)(chu)血(xue)(xue)(xue)(xue)(xue);胃黏膜淺(qian)表(biao)性(xing)凹陷,缺損中間有(you)血(xue)(xue)(xue)(xue)(xue)管行走,表(biao)面(mian)有(you)血(xue)(xue)(xue)(xue)(xue)凝(ning)塊附著;偶爾可見小血(xue)(xue)(xue)(xue)(xue)管突(tu)出(chu)(chu)正常黏膜的(de)表(biao)面(mian),且有(you)搏動(dong)性(xing)出(chu)(chu)血(xue)(xue)(xue)(xue)(xue)。內(nei)(nei)(nei)鏡(jing)對動(dong)靜脈型血(xue)(xue)(xue)(xue)(xue)管畸形的(de)診斷(duan)存(cun)在一定的(de)困難,有(you)報道確診率僅(jin)為37%。在病(bing)(bing)灶(zao)活動(dong)性(xing)出(chu)(chu)血(xue)(xue)(xue)(xue)(xue),胃腔內(nei)(nei)(nei)大(da)量積血(xue)(xue)(xue)(xue)(xue)或(huo)血(xue)(xue)(xue)(xue)(xue)凝(ning)塊掩蓋了(le)出(chu)(chu)血(xue)(xue)(xue)(xue)(xue)點,內(nei)(nei)(nei)鏡(jing)難以發現病(bing)(bing)灶(zao);即使出(chu)(chu)血(xue)(xue)(xue)(xue)(xue)停止,較小的(de)病(bing)(bing)灶(zao)也易于忽視。

13.2 選擇性血管造影

對動(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)脈(mo)(mo)型(xing)血(xue)(xue)管(guan)畸(ji)(ji)(ji)形的(de)確(que)診(zhen)(zhen)率為(wei)(wei)20%~30%,Burham報道9例(li)術前采用選(xuan)擇性腹(fu)(fu)腔(qiang)動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)造影的(de)患者,僅3例(li)獲得確(que)診(zhen)(zhen)。動(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)脈(mo)(mo)型(xing)血(xue)(xue)管(guan)畸(ji)(ji)(ji)形的(de)血(xue)(xue)管(guan)造影特征(zheng)為(wei)(wei):造影劑經胃(wei)左動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)進(jin)入(ru)(ru)胃(wei)近(jin)端,迅速(su)從黏膜點狀糜爛區(qu)進(jin)入(ru)(ru)胃(wei)腔(qiang),動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)形態(tai)正常,沒(mei)有(you)動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)瘤的(de)形成或(huo)動(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)脈(mo)(mo)分流的(de)存在。但(dan)是,選(xuan)擇性腹(fu)(fu)腔(qiang)動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)造影必須在有(you)活動(dong)(dong)(dong)(dong)(dong)(dong)性出(chu)血(xue)(xue)時才能成功地表示出(chu)血(xue)(xue)的(de)部位,若出(chu)血(xue)(xue)停止,可(ke)考(kao)慮將導管(guan)留(liu)置在血(xue)(xue)管(guan)內24h,一(yi)旦(dan)有(you)出(chu)血(xue)(xue)即行造影可(ke)望獲得診(zhen)(zhen)斷。一(yi)般認(ren)為(wei)(wei),動(dong)(dong)(dong)(dong)(dong)(dong)靜(jing)脈(mo)(mo)型(xing)血(xue)(xue)管(guan)畸(ji)(ji)(ji)形患者經多次(ci)內鏡檢查仍陰性,可(ke)采用選(xuan)擇性腹(fu)(fu)腔(qiang)動(dong)(dong)(dong)(dong)(dong)(dong)脈(mo)(mo)造影,以(yi)明確(que)診(zhen)(zhen)斷。

13.3 核素檢查

采(cai)用(yong)99Tc紅細(xi)胞(bao)示(shi)蹤技術診斷(duan)動靜脈(mo)型血管(guan)畸形已(yi)有成功的報(bao)道,在內鏡檢(jian)查、選擇(ze)性腹腔(qiang)動脈(mo)造影(ying)均未發現出血點時(shi),99Tc紅細(xi)胞(bao)檢(jian)查有助(zhu)于發現出血點。

14 診斷 由于動(dong)靜(jing)脈型血管畸形的(de)臨床表現缺乏(fa)特異(yi)性(xing),內鏡、選擇性(xing)血管造影、核(he)素(su)示蹤等檢(jian)查方(fang)法有助于動(dong)靜(jing)脈型血管畸形的(de)術前診斷,并為手(shou)術治療提(ti)供重要(yao)的(de)依據,部分患者在剖(pou)腹探查和尸檢(jian)病理檢(jian)查時(shi)方(fang)能獲(huo)得診斷。

術(shu)中診(zhen)斷:動(dong)(dong)靜(jing)脈(mo)(mo)(mo)型血(xue)(xue)(xue)管(guan)(guan)畸(ji)形(xing)(xing)多數是在(zai)(zai)急(ji)診(zhen)手術(shu)探(tan)查時確診(zhen),術(shu)中探(tan)查胃(wei)(wei)體(ti)表形(xing)(xing)態正常(chang)(chang),未發(fa)現(xian)(xian)(xian)消化道(dao)潰瘍病(bing)(bing)(bing)(bing)灶或門(men)靜(jing)脈(mo)(mo)(mo)高壓性(xing)(xing)食管(guan)(guan)靜(jing)脈(mo)(mo)(mo)曲(qu)張等(deng)出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)病(bing)(bing)(bing)(bing)因時,應考慮胃(wei)(wei)黏(nian)(nian)(nian)膜(mo)病(bing)(bing)(bing)(bing)變所(suo)致出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue),沿胃(wei)(wei)大彎側(ce)切開胃(wei)(wei)壁。吸出(chu)(chu)(chu)(chu)(chu)(chu)胃(wei)(wei)腔內大量積(ji)血(xue)(xue)(xue)和血(xue)(xue)(xue)凝(ning)(ning)塊,仔(zi)細(xi)檢查胃(wei)(wei)黏(nian)(nian)(nian)膜(mo)有(you)無出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)性(xing)(xing)病(bing)(bing)(bing)(bing)灶,若未發(fa)現(xian)(xian)(xian)胃(wei)(wei)黏(nian)(nian)(nian)膜(mo)明顯病(bing)(bing)(bing)(bing)變如(ru)血(xue)(xue)(xue)管(guan)(guan)瘤等(deng),應注意檢查賁門(men)區胃(wei)(wei)黏(nian)(nian)(nian)膜(mo)。一般情況(kuang)下,動(dong)(dong)靜(jing)脈(mo)(mo)(mo)型血(xue)(xue)(xue)管(guan)(guan)畸(ji)形(xing)(xing)患(huan)者(zhe)胃(wei)(wei)黏(nian)(nian)(nian)膜(mo)正常(chang)(chang),黏(nian)(nian)(nian)膜(mo)表面無靜(jing)脈(mo)(mo)(mo)曲(qu)張,僅在(zai)(zai)胃(wei)(wei)賁門(men)區小彎側(ce)可(ke)見活躍的出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)點,仔(zi)細(xi)觀(guan)察發(fa)現(xian)(xian)(xian)胃(wei)(wei)黏(nian)(nian)(nian)膜(mo)有(you)針尖(jian)圓點樣淺表性(xing)(xing)糜(mi)爛(lan)或黏(nian)(nian)(nian)膜(mo)缺(que)(que)損或紅疹(zhen)樣隆(long)起,表面有(you)出(chu)(chu)(chu)(chu)(chu)(chu)汗(han)樣滲血(xue)(xue)(xue)或噴射(she)樣出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue),病(bing)(bing)(bing)(bing)灶周圍(wei)黏(nian)(nian)(nian)膜(mo)正常(chang)(chang);若出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)停止(zhi),黏(nian)(nian)(nian)膜(mo)表面可(ke)有(you)血(xue)(xue)(xue)凝(ning)(ning)塊附著(zhu),用吸收性(xing)(xing)明膠海綿擦除(chu)血(xue)(xue)(xue)凝(ning)(ning)塊即可(ke)發(fa)現(xian)(xian)(xian)出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue)點;亦有(you)的病(bing)(bing)(bing)(bing)灶表現(xian)(xian)(xian)為胃(wei)(wei)黏(nian)(nian)(nian)膜(mo)淺表性(xing)(xing)缺(que)(que)損的中央有(you)小動(dong)(dong)脈(mo)(mo)(mo)突出(chu)(chu)(chu)(chu)(chu)(chu)于胃(wei)(wei)腔,且有(you)活動(dong)(dong)性(xing)(xing)出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue);探(tan)查一旦發(fa)現(xian)(xian)(xian)胃(wei)(wei)黏(nian)(nian)(nian)膜(mo)淺表性(xing)(xing)局限性(xing)(xing)病(bing)(bing)(bing)(bing)灶伴有(you)活動(dong)(dong)性(xing)(xing)出(chu)(chu)(chu)(chu)(chu)(chu)血(xue)(xue)(xue),即可(ke)考慮為動(dong)(dong)靜(jing)脈(mo)(mo)(mo)型血(xue)(xue)(xue)管(guan)(guan)畸(ji)形(xing)(xing),只要(yao)充分認識動(dong)(dong)靜(jing)脈(mo)(mo)(mo)型血(xue)(xue)(xue)管(guan)(guan)畸(ji)形(xing)(xing)的特殊位置和病(bing)(bing)(bing)(bing)理特征,術(shu)中探(tan)查即可(ke)獲得(de)明確診(zhen)斷。

15 鑒(jian)別(bie)診(zhen)斷 在診(zhen)斷動靜脈型血(xue)管(guan)畸形時應注意與MalloyWeiss撕裂(lie)和出血(xue)性胃血(xue)管(guan)擴張鑒(jian)別(bie)。

16 動(dong)靜脈(mo)(mo)型血(xue)(xue)管(guan)畸形的治療(liao) 動(dong)靜脈(mo)(mo)型血(xue)(xue)管(guan)畸形具有較高的病(bing)死率,死亡(wang)的主(zhu)要(yao)原因是(shi)失血(xue)(xue)性休克和多器官功能衰竭。早(zao)期診(zhen)斷并給予(yu)有效治療(liao)至(zhi)關重要(yao)。可選擇(ze)內(nei)鏡治療(liao)、選擇(ze)性胃左動(dong)脈(mo)(mo)栓塞和手(shou)術治療(liao)。

16.1 內鏡治療

多數(shu)動靜脈型血管(guan)畸形患者經內(nei)鏡治(zhi)(zhi)(zhi)療(liao)可獲得(de)成(cheng)功(gong)。文獻報道內(nei)鏡止血成(cheng)功(gong)率達96%。內(nei)鏡治(zhi)(zhi)(zhi)療(liao)的方法(fa)有(you)注射療(liao)法(fa),熱探頭、微波(bo)、高(gao)頻(pin)電凝、激光等熱治(zhi)(zhi)(zhi)療(liao)和止血夾(jia)、圈套器(qi)等器(qi)械治(zhi)(zhi)(zhi)療(liao)。

16.1.1 (1)注(zhu)射(she)治療 是最簡單(dan)的治療方法。早在20世(shi)紀(ji)70年代(dai)就有人(ren)試(shi)用1%乙(yi)氧(yang)硬化醇內(nei)鏡(jing)下(xia)注(zhu)射(she)。局部注(zhu)射(she)后黏膜(mo)組織水(shui)腫(zhong),增高出血(xue)(xue)(xue)灶周圍(wei)壓力,壓迫(po)血(xue)(xue)(xue)管(guan),促(cu)使血(xue)(xue)(xue)管(guan)內(nei)血(xue)(xue)(xue)栓形成,注(zhu)射(she)腎上腺素還(huan)可使局部血(xue)(xue)(xue)管(guan)收縮,從而達到止血(xue)(xue)(xue)作用。注(zhu)射(she)方法:常規內(nei)鏡(jing)檢查(cha),發現(xian)出血(xue)(xue)(xue)灶并充(chong)分暴露出血(xue)(xue)(xue)部位(wei),經內(nei)鏡(jing)活檢孔道(dao)送入內(nei)鏡(jing)注(zhu)射(she)針(zhen),同時(shi)將選用藥物先灌注(zhu)內(nei)鏡(jing)注(zhu)射(she)針(zhen)管(guan)內(nei),距出血(xue)(xue)(xue)血(xue)(xue)(xue)管(guan)1~2 mm處,分3~5點注(zhu)射(she),深度2~3mm,有效為新鮮血(xue)(xue)(xue)液變黑,然(ran)后用冰水(shui)沖洗血(xue)(xue)(xue)凝塊,必要時(shi)補充(chong)注(zhu)射(she)。常用藥物有:

①無(wu)水乙(yi)醇(chun):每點宜0.1~0.2ml,總量1~2ml。

②硬(ying)(ying)化(hua)劑:5%魚肝(gan)油(you)酸(suan)酸(suan)鈉或1%乙氧硬(ying)(ying)化(hua)醇,每點注0.2~0.5ml,總(zong)量2~4ml。

③高張鈉腎上(shang)腺素液(ye)(HSE):每點0.5ml,總量不超過(guo)10ml。注射硬化劑(ji)和無水(shui)乙醇的(de)不良反應有潰瘍形成(cheng),注意掌握劑(ji)量和深度。

16.1.2 (2)熱(re)(re)(re)探(tan)(tan)(tan)頭(tou)(tou)(tou)凝(ning)固治(zhi)療 熱(re)(re)(re)探(tan)(tan)(tan)頭(tou)(tou)(tou)凝(ning)固止血(xue)(xue)是將特制的熱(re)(re)(re)探(tan)(tan)(tan)頭(tou)(tou)(tou),經內(nei)(nei)鏡(jing)活檢孔道插入胃內(nei)(nei),在直視(shi)下(xia)接觸出(chu)(chu)血(xue)(xue)灶(zao),使蛋白質凝(ning)固而止血(xue)(xue),在內(nei)(nei)鏡(jing)直視(shi)下(xia),熱(re)(re)(re)探(tan)(tan)(tan)頭(tou)(tou)(tou)對(dui)準出(chu)(chu)血(xue)(xue)灶(zao),注水(shui)沖(chong)洗病(bing)變(bian)(bian)表面的血(xue)(xue)凝(ning)塊。然后將熱(re)(re)(re)探(tan)(tan)(tan)頭(tou)(tou)(tou)輕壓于出(chu)(chu)血(xue)(xue)灶(zao),并行熱(re)(re)(re)凝(ning)固。病(bing)變(bian)(bian)組織顏色(se)變(bian)(bian)蒼白后,注水(shui)使探(tan)(tan)(tan)頭(tou)(tou)(tou)冷卻并與凝(ning)固組織分離。如仍有出(chu)(chu)血(xue)(xue),可(ke)反復幾次,直到(dao)出(chu)(chu)血(xue)(xue)停(ting)止。止血(xue)(xue)后,觀察(cha)數(shu)分鐘,確定再無出(chu)(chu)血(xue)(xue)時(shi),即可(ke)退出(chu)(chu)內(nei)(nei)鏡(jing)。熱(re)(re)(re)探(tan)(tan)(tan)頭(tou)(tou)(tou)凝(ning)固止血(xue)(xue)方(fang)法簡單(dan),療效確實、安全,儀器價(jia)格遠(yuan)較激光器低廉。

16.1.3 (3)微(wei)(wei)波(bo)(bo)凝(ning)固(gu)治(zhi)(zhi)療 內(nei)(nei)鏡微(wei)(wei)波(bo)(bo)凝(ning)固(gu)治(zhi)(zhi)療是集中微(wei)(wei)波(bo)(bo)能量于(yu)一小的區域,使(shi)組(zu)(zu)織(zhi)蛋白凝(ning)固(gu)而達到止血目的的一種治(zhi)(zhi)療方(fang)法。一般使(shi)用(yong)輸出波(bo)(bo)長12cm,頻率2450 MHz,功(gong)率100w的微(wei)(wei)波(bo)(bo)。在(zai)內(nei)(nei)鏡直視下,微(wei)(wei)波(bo)(bo)探頭對準并(bing)輕(qing)壓(ya)出血灶,行(xing)微(wei)(wei)波(bo)(bo)凝(ning)固(gu)。功(gong)率調整在(zai)40~50w(50~60mA),凝(ning)固(gu)時(shi)間在(zai)10~20s,致(zhi)病變(bian)組(zu)(zu)織(zhi)顏色變(bian)蒼白、出血停止即可。應用(yong)微(wei)(wei)波(bo)(bo)凝(ning)固(gu)止血后,組(zu)(zu)織(zhi)修復(fu)多(duo)在(zai)2~4周內(nei)(nei)完成。內(nei)(nei)鏡下微(wei)(wei)波(bo)(bo)凝(ning)固(gu)止血操(cao)作簡便,設備造(zao)價低廉(lian)。

16.1.4 (4)高頻(pin)(pin)電(dian)(dian)(dian)(dian)凝治(zhi)療 利用(yong)(yong)高頻(pin)(pin)電(dian)(dian)(dian)(dian)流(liu)在(zai)局(ju)部組織(zhi)產(chan)生熱效(xiao)應,使蛋白質凝固(gu),血(xue)(xue)(xue)(xue)管(guan)栓塞達到(dao)止(zhi)(zhi)血(xue)(xue)(xue)(xue)目的(de)。電(dian)(dian)(dian)(dian)凝治(zhi)療對組織(zhi)損傷少,只有在(zai)明(ming)確出(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)點時方能應用(yong)(yong),大(da)量出(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)影(ying)響電(dian)(dian)(dian)(dian)凝的(de)止(zhi)(zhi)血(xue)(xue)(xue)(xue)效(xiao)果。內(nei)鏡檢查(cha)發現(xian)出(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)病灶后,即連接高頻(pin)(pin)電(dian)(dian)(dian)(dian)源,并在(zai)病人小腿部放(fang)電(dian)(dian)(dian)(dian)極板,試(shi)驗確定通電(dian)(dian)(dian)(dian)正常。凝固(gu)電(dian)(dian)(dian)(dian)流(liu)強度通常選(xuan)用(yong)(yong)2或3,時間1~2s。選(xuan)用(yong)(yong)合適探頭(tou),在(zai)內(nei)鏡直(zhi)視下將(jiang)電(dian)(dian)(dian)(dian)凝頭(tou)按壓在(zai)出(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)部位,接通凝固(gu)電(dian)(dian)(dian)(dian)流(liu),可(ke)反復數(shu)次,直(zhi)至(zhi)組織(zhi)發白出(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)停(ting)止(zhi)(zhi)。止(zhi)(zhi)血(xue)(xue)(xue)(xue)后,觀(guan)察(cha)數(shu)分鐘,確無再(zai)出(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue),可(ke)退出(chu)(chu)(chu)(chu)電(dian)(dian)(dian)(dian)凝頭(tou)及(ji)內(nei)鏡。電(dian)(dian)(dian)(dian)凝后電(dian)(dian)(dian)(dian)極與灼焦(jiao)組織(zhi)黏附(fu)在(zai)一起(qi),若用(yong)(yong)力牽拉探頭(tou)易帶下焦(jiao)痂(jia)組織(zhi),引(yin)起(qi)再(zai)出(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)。因而(er)在(zai)去除(chu)電(dian)(dian)(dian)(dian)凝頭(tou)時,必須先停(ting)止(zhi)(zhi)通電(dian)(dian)(dian)(dian),以(yi)防止(zhi)(zhi)繼發性出(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)。高頻(pin)(pin)電(dian)(dian)(dian)(dian)凝止(zhi)(zhi)血(xue)(xue)(xue)(xue)操作(zuo)簡單,適用(yong)(yong)于噴射狀出(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)、活動性滲血(xue)(xue)(xue)(xue)、有半球(qiu)型血(xue)(xue)(xue)(xue)管(guan)顯露及(ji)散在(zai)的(de)出(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)點等各種(zhong)出(chu)(chu)(chu)(chu)血(xue)(xue)(xue)(xue)情況。

16.1.5 (5)激(ji)(ji)光(guang)(guang)(guang)(guang)治(zhi)療 利用激(ji)(ji)光(guang)(guang)(guang)(guang)照(zhao)射(she)組織表面被吸(xi)收后(hou)(hou)可(ke)轉變為熱能(neng)的(de)原理(li),被照(zhao)射(she)局部(bu)組織吸(xi)收光(guang)(guang)(guang)(guang)能(neng)后(hou)(hou)即產生高溫,使蛋(dan)白凝固,水分汽化,達(da)(da)到(dao)光(guang)(guang)(guang)(guang)凝止(zhi)血(xue)目的(de)。內鏡(jing)(jing)檢(jian)(jian)查(cha)找到(dao)出(chu)血(xue)病灶后(hou)(hou),自活檢(jian)(jian)孔(kong)道(dao)送入石英纖維電極,對準出(chu)血(xue)病灶,距離(li)0.5~1.0cm,每(mei)次1~3s,重(zhong)復照(zhao)射(she),至出(chu)血(xue)灶黏膜發白或(huo)呈深棕色(se)表示出(chu)血(xue)停止(zhi)。內鏡(jing)(jing)下(xia)激(ji)(ji)光(guang)(guang)(guang)(guang)照(zhao)射(she)止(zhi)血(xue)效(xiao)果可(ke)靠,凡是內鏡(jing)(jing)能(neng)到(dao)達(da)(da)的(de)胃(wei)腸(chang)(chang)道(dao)部(bu)位(wei)均可(ke)使用。但激(ji)(ji)光(guang)(guang)(guang)(guang)光(guang)(guang)(guang)(guang)凝治(zhi)療儀器價格昂貴,移(yi)動(dong)不便(bian)是其缺點。此(ci)外,激(ji)(ji)光(guang)(guang)(guang)(guang)止(zhi)血(xue)治(zhi)療可(ke)引起一些嚴重(zhong)的(de)并發癥(zheng),如胃(wei)腸(chang)(chang)道(dao)穿孔(kong)、出(chu)血(xue)及胃(wei)腸(chang)(chang)脹氣等。造成胃(wei)腸(chang)(chang)穿孔(kong)的(de)主要原因為選擇功率(lv)過大,或(huo)1次照(zhao)射(she)時(shi)間過長。穿孔(kong)的(de)發生率(lv)為1%。

16.1.6 (6)注射聯(lian)合熱(re)治療(liao)(liao) 注射治療(liao)(liao)合并(bing)使(shi)用(yong)上述熱(re)治療(liao)(liao)的一(yi)種,可以提(ti)高(gao)(gao)止(zhi)(zhi)血效果,藥物注入(ru)后暫(zan)時(shi)性止(zhi)(zhi)血,提(ti)高(gao)(gao)出(chu)血點的可見(jian)性,使(shi)得熱(re)治療(liao)(liao)止(zhi)(zhi)血更為(wei)精確和有效。

16.1.7 (7)止血(xue)(xue)夾治療 止血(xue)(xue)夾子(zi)(zi)原理(li)類似活檢鉗,但(dan)鉗瓣呈(cheng)夾子(zi)(zi)狀,夾住小血(xue)(xue)管后(hou)夾子(zi)(zi)可(ke)與操作(zuo)部解體而仍鉗住血(xue)(xue)管。數天后(hou)脫落時有血(xue)(xue)凝塊形成,從(cong)而達到止血(xue)(xue)目的。止血(xue)(xue)夾子(zi)(zi)主要(yao)適(shi)用于血(xue)(xue)管顯露性(xing)病(bing)變出血(xue)(xue),1次不成功(gong),可(ke)重(zhong)復數次,直至止血(xue)(xue)滿意。

16.1.8 (8)套扎治療(liao) 套扎治療(liao)方法與其他內(nei)鏡治療(liao)方法比(bi)較操作相對(dui)(dui)容易(yi),特別是(shi)(shi)食管胃(wei)結(jie)合部和上部胃(wei)體后(hou)壁的病變(bian)。直徑(jing)1cm以(yi)(yi)內(nei)的病變(bian)可(ke)(ke)以(yi)(yi)套扎,病變(bian)可(ke)(ke)以(yi)(yi)吸進內(nei)鏡頂端的透明帽,視(shi)野清晰,止血(xue)效(xiao)果(guo)肯定。但(dan)是(shi)(shi)套扎器的安(an)裝花費時間(jian)。對(dui)(dui)于(yu)注(zhu)射治療(liao)后(hou)無效(xiao)或復發出(chu)血(xue)者可(ke)(ke)以(yi)(yi)選擇(ze)。術后(hou)結(jie)扎部位黏膜(mo)表面(mian)形(xing)成(cheng)潰瘍,不形(xing)成(cheng)復發出(chu)血(xue)。

16.2 栓塞治療

選(xuan)(xuan)擇(ze)性(xing)腹腔動(dong)脈(mo)造影和栓塞(sai)治(zhi)(zhi)(zhi)療動(dong)靜脈(mo)型血管畸(ji)形報道較少。對(dui)于內鏡治(zhi)(zhi)(zhi)療失(shi)敗(bai)而又不(bu)能耐受外科手(shou)術者應作為特別有用的治(zhi)(zhi)(zhi)療手(shou)段(duan)。文獻報道4例患者在行選(xuan)(xuan)擇(ze)性(xing)腹腔動(dong)脈(mo)造影的同時(shi)進(jin)行胃左動(dong)脈(mo)栓塞(sai),3例經治(zhi)(zhi)(zhi)療后出血停止(zhi),另1例治(zhi)(zhi)(zhi)療失(shi)敗(bai)而做手(shou)術治(zhi)(zhi)(zhi)療。選(xuan)(xuan)用栓塞(sai)治(zhi)(zhi)(zhi)療必須具備3個(ge)條件:

(1)插管超選擇性(xing)進入胃左動脈(mo)。

(2)血(xue)管造影明確病灶和出血(xue)點而無(wu)側支血(xue)管。

(3)生命(ming)體征平穩,有足夠時間從容地進行栓塞治療。

16.3 手術治療

過去認為手(shou)術(shu)是治療(liao)(liao)(liao)動(dong)靜(jing)脈型血(xue)(xue)(xue)管(guan)畸(ji)形(xing)的(de)(de)首(shou)選方(fang)法。隨著內(nei)鏡(jing)治療(liao)(liao)(liao)的(de)(de)進(jin)步,手(shou)術(shu)治療(liao)(liao)(liao)已趨向先行(xing)內(nei)鏡(jing)治療(liao)(liao)(liao),內(nei)鏡(jing)治療(liao)(liao)(liao)無效(xiao)者則(ze)應(ying)果斷外科手(shou)術(shu)。手(shou)術(shu)方(fang)法包括出血(xue)(xue)(xue)點電凝、縫扎止血(xue)(xue)(xue)、近端(duan)胃大部(bu)切(qie)除(chu)和局部(bu)楔(xie)形(xing)切(qie)除(chu)。電凝和縫扎方(fang)法簡單,但術(shu)后(hou)出血(xue)(xue)(xue)易復(fu)發(fa),近來更主(zhu)張行(xing)廣泛(fan)性(xing)胃楔(xie)形(xing)切(qie)除(chu)術(shu),因為恒(heng)徑動(dong)脈在胃黏膜(mo)行(xing)程較長,切(qie)除(chu)后(hou)即可去除(chu)病因,避免出血(xue)(xue)(xue)復(fu)發(fa),又可將切(qie)除(chu)標本(ben)進(jin)行(xing)病理檢(jian)查(cha)獲得最終(zhong)診斷。手(shou)術(shu)時應(ying)仔(zi)細檢(jian)查(cha)胃黏膜(mo),明確動(dong)靜(jing)脈型血(xue)(xue)(xue)管(guan)畸(ji)形(xing)病灶(zao)的(de)(de)位(wei)置,當出血(xue)(xue)(xue)點或病灶(zao)不能明確時,禁忌進(jin)行(xing)盲(mang)目的(de)(de)BillrothⅡ式胃大部(bu)切(qie)除(chu),若進(jin)行(xing)這樣的(de)(de)手(shou)術(shu),術(shu)后(hou)一定會再出血(xue)(xue)(xue),預后(hou)很(hen)差。

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